The configuration of total hip arthroplasty (THA) implants has constantly evolved since they were first introduced. One of the key components of THA design is the diameter of the prosthetic femoral head. It has been well established that the risk of dislocation is lower as the head diameter increases. But head diameter impacts other variables beyond joint stability: wear, cam-type impingement, range of motion, restoration of biomechanics, proprioception and groin pain. The introduction of highly cross-linked polyethylene and hard-on-hard bearings has allowed surgeons to implant large-diameter heads that almost completely eliminate the risk of dislocation. But as a result, cup liners have become thinner. With femoral head diameters up to 36mm, the improvement in joint range of motion, delay in cam-type impingement and reduction in dislocation risk have been clearly demonstrated. Conversely, large-diameter heads do not provide any additional improvements. If an “ecologically sound” approach to hip replacement is embraced (e.g. keeping the native femoral head diameter), hip resurfacing with a metal-on-metal bearing must be carried out. The reliability of large-diameter femoral heads in the longer term is questionable. Large-diameter ceramic-on-ceramic bearings may be plagued by the same problems as metal-on-metal bearings: groin pain, squeaking, increased stiffness, irregular lubrication, acetabular loosening and notable friction at the Morse taper. These possibilities require us to be extra careful when using femoral heads with a diameter greater than 36mm.